| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
612 |
345 |
$72K |
| D0120 |
Periodic oral evaluation - established patient |
1,485 |
1,479 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,960 |
2,333 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
637 |
637 |
$36K |
| D1120 |
Prophylaxis - child |
997 |
995 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,770 |
1,765 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
349 |
147 |
$20K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
263 |
151 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
941 |
938 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
657 |
628 |
$8K |
| D1110 |
Prophylaxis - adult |
82 |
81 |
$5K |
| D1351 |
Sealant - per tooth |
123 |
30 |
$2K |
| D2140 |
|
41 |
28 |
$2K |
| D0350 |
|
224 |
119 |
$2K |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$540.00 |
| D9430 |
|
15 |
13 |
$204.00 |
| D1330 |
|
553 |
550 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
13 |
$0.00 |